06/13/2013    Hartley Miltchin, DPM

CA Podiatrist Uses Minimal Incision with Fixation for Bunion Repair (Randall Brower, DPM)

Here we go once again "bashing" our colleagues.
I learned many years ago that "use what works
best in your hands and has the best outcome for
your patients."

I have been performing a significant number of
minimally invasive bunion procedures, weekly, for
the past 31 years. I have never had to repeat a
bunion procedure because it has returned. I have
never had a patient with a non-union, never had a
patient with hallux varus. I have never had a
patient with a transfer lesion, nor have I ever
had a malpractice suit from an unhappy bunion
surgical patient.

In my hands, minimally invasive bunion surgery
(without sutures, internal fixation etc.) has
worked wonderfully. My patients lead busy lives
and can't afford to be immobile for weeks. I
NEVER judge other practitioners on what
procedures they perform. The bottom line is, what
will provide the BEST result for the patient. No,
minimally invasive surgery is not "blind"
surgery, ever heard of fluoroscopy?

What will you say to orthopedic surgeons who
perform minimally invasive knee surgery, spinal
ecompression/implants, plantar fasciotomies,
condylectomies, all minimally invasive? General
surgeons routinely remove gall bladders through
the naval. In fact, my colleagues and myself, who
practice MIS, routinely get orthopedic referrals
because they have seen the positive results and
patient satisfaction.

MIS is not a panacea as is any procedure and
quite often I refer patients to my colleagues,
for surgery in the traditional way. Minimally
invasive procedures is the 'wave of the future'
in medicine as more specialists realize the
benefits. With Obamacare, podiatrists will soon
not be able to internally fixate because of cost
restrictions. It may be time to "see outside the
box" and explore alternative surgical
procedures.

It's time that podiatrists "stop eating their
young" and stop judging others in how they
practice. Just do whatever it takes to realize a
great outcome and a happy patient, those are what
are REALLY important.

Hartley Miltchin, DPM, Toronto, Canada,
ilovebunions@aol.com

Other messages in this thread:

---

06/11/2013    Alireza Khosroabadi, DPM

CA Podiatrist Uses Minimal Incision with Fixation for Bunion Repair (Randall Brower, DPM)

Let me start by saying that the tone in Dr.
Brower's comment on PM News was full of
criticism, negativity and bitterness. I am very
shocked to hear such a closed minded comment. Dr.
Brower, you need to keep up with your readings of
medical journals. The percutaneous bunionectomy
that I perform was published in JBJS few years
ago. It was a 5-year follow up of 118 feet with
91% satisfaction rate.

I am a very well respected surgeon in my
community and collaborate with other foot and
ankle surgeons as well as orthopedic surgeons on
regular basis. My entire office is dedicated to
serve our patients and I do what is the absolute
best for my patients. I find your comments very
unjust since you have no clue of how this
procedure is performed. You don't even have an
open mind to search/question the techniques in
this procedure before jumping the gun.

First, you need to watch this video and see how
this procedure is done. Any bone surgeon knows
that the less you dissect the soft tissue envelop
around the osteotomy/fracture the more stable it
stays. In this procedure the osteotomy takes
advantage of maintaining the soft tissue envelope
(which plays a huge role in stabilization/healing
the bone). I have modified this procedure and
instead of using a Lindemann bone-cutter.

I use a hook osteotome to perform my osteotomy.
This is a pea-body osteotomy and YES you can
address both IM and PASA via this osteotomy. The
K-wire is inserted medially in such a fashion
that it blocks the ROM of hallux and on the
lateral side the soft tissue envelope keep things
stable.

I have performed over 30 of these now and beside
a slight pin track infection, I have not
encountered any major complications. My patients
walk day 2 using a surgical shoe (no crutches).
As you can see in these x-rays that there is no
signs of callus formation unless you are seeing
something I am not seeing.

The entire surgical/medical community is trying
to utilize MIS as much as possible since patients
will recover faster and complication rates are
tremendously lower. So, am I doing a huge
disservice to the patients and to our profession?
I beg the difference. I have had a very good
training and spend an additional year training at
(Rubin Institute for Advance Orthopedics,
Baltimore, MD). I learned to do surgery based on
principles of deformity correction. I have
learned to push the envelope to advance foot and
ankle surgery.

In my opinion, if our new generation of surgeons(
past 20-30 years) did not do this we would have
not had these advancements in podiatric field. I
am not advocating my procedure to be the main
stream technique for all bunions, however
patients with mild to moderate bunion can benefit
from this procedure (done correctly). 95% of my
patients are walking without crutches on day 2
and are healed by week 5.

I can only assume that minimal incision surgery
and not insulting the soft tissue envelope are
the only contributing factors to these results.
I utilize an osteotome for my procedure because
of the fact that osteotomies via osteotome heal
significantly faster then osteotomies done with a
power saw ( I don't need to go in to details on
this).

I hope that next time Dr. Brower tries to take a
shot at one of his colleges, he should get a
complete picture of what it is he is criticizing?
I must say that I thought the generation that
kept worrying about orthopedists was retiring ….
no offense.

Here is the link to the procedure
http://youtu.be/zYjzGN-HfLY

Drs. wanting to use this method: Fluoroscopy is a
must for this procedure. I don't recommend
utilizing osteotome if you are not comfortable
doing so. This procedure its not a walk in the
park, as a matter of fact very challenging and if
you are not surgically inclined you can get
yourself in trouble very easily. On the other
hand if you get a hang of it, your patients will
greatly appreciate the benefits of minimal
scaring/pain/faster healing/ no loss of ROM.
After doing 30 of these , I am able to perform
this procedure in ' 15 minutes.

Alireza Khosroabadi, DPM, Los Angeles, CA,
drk@fixmyfoot.com